What is the treatment for pneumonia?

Treatment of Pneumonia

The treatment of pneumonia requires appropriate antibiotic therapy based on severity, with oral amoxicillin for non-severe community-acquired pneumonia and combination therapy with a beta-lactam plus macrolide for severe pneumonia. 1

Treatment Based on Severity

Non-Severe Community-Acquired Pneumonia

• For patients treated in the community or those admitted to hospital for non-clinical reasons, oral amoxicillin monotherapy is recommended 1
• For patients who have failed to respond to amoxicillin prior to admission, a macrolide (erythromycin or clarithromycin) may be suitable 1
• When oral treatment is contraindicated, parenteral options include intravenous ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 1
• Treatment duration for uncomplicated pneumonia should be 7 days 1

Severe Community-Acquired Pneumonia

• Patients with severe pneumonia should be treated immediately with parenteral antibiotics 1
• An intravenous combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) together with a macrolide (clarithromycin or erythromycin) is preferred 1
• For patients intolerant of β-lactams or macrolides, a fluoroquinolone with enhanced activity against S. pneumoniae (levofloxacin) together with intravenous benzyl-penicillin is an alternative 1
• Treatment duration for severe microbiologically undefined pneumonia should be 10 days, extended to 14-21 days for legionella, staphylococcal, or gram-negative enteric bacilli pneumonia 1, 2

Route of Administration

• Oral route is recommended for non-severe pneumonia when there are no contraindications 1
• Patients initially treated with parenteral antibiotics should be transferred to oral therapy when clinical improvement occurs and temperature has been normal for 24 hours 1
• The choice of route should be reviewed initially on the "post take" round and then daily 1

Management of Treatment Failure

• For patients who fail to improve, conduct a thorough clinical review including examination, prescription chart, and all available investigation results 1, 3
• Consider additional investigations: repeat chest radiograph, CRP, white cell count, and further microbiological testing 1, 3
• For non-severe pneumonia treated with amoxicillin monotherapy, add or substitute a macrolide 1, 3
• For non-severe pneumonia on combination therapy, consider changing to a fluoroquinolone with effective pneumococcal coverage 1, 3
• For severe pneumonia not responding to combination treatment, consider adding rifampicin 1, 3

Specific Pathogens

• Levofloxacin is indicated for community-acquired pneumonia due to susceptible strains of S. pneumoniae, H. influenzae, H. parainfluenzae, M. catarrhalis, C. pneumoniae, L. pneumophila, or M. pneumoniae 4
• When a specific pathogen has been identified, adjust therapy according to susceptibility patterns 1
• For pneumococcal pneumonia with penicillin MIC values ≥4 mg/L, consider a newer fluoroquinolone, vancomycin, or clindamycin 3

Prevention

• Influenza vaccination is recommended for high-risk groups including those with chronic lung, heart, renal and liver disease, diabetes mellitus, immunosuppression, and those over 65 years 1
• Pneumococcal vaccination is recommended for those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1

Common Pitfalls and Caveats

• New fluoroquinolones are not recommended as first-line agents or for community use but may provide a useful alternative in selected hospitalized patients 1
• Delaying appropriate antibiotic therapy can increase mortality, so prompt reassessment and change of antibiotics is essential when treatment failure is suspected 3, 5
• Fluoroquinolones should be used with caution due to risk of QT prolongation, especially in elderly patients or those with cardiac conditions 6
• For patients with hospital-acquired pneumonia, broader coverage may be needed to address potential multidrug-resistant pathogens 1, 7